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1、Ethics Consult Service: A Case StudyWalter Limehouse, MD, MAMUSC Ethics CommitteeObjectivesnUsing a case studyn nexplore ethical principlesn ndiscover how the ECS may help resolve ethical concerns in patient management.Case Study: 79 year old woman has aged gracefullyn Very independent, lives alone.
2、n Ten days ago while out shopping n experienced a massive stroke n n required endotracheal intubation by EMS. nShe remains in ICU on a ventilator.Case Study: 79 year old woman has aged gracefullynNo advance directive. nWidow with three children Case Study: 79 year old woman has aged gracefullynlocal
3、 daughtern n “dont keep mom on ventilator” n n admits no related talks with mothern n daughter from NYC newly arrivedn n “do everything”n son from CA - travels frequentlyn n not yet notifiedCase Study: 79 year old woman has aged gracefullynMD wants n nwithdraw ventilator n ntracheostomy and feeding
4、tubeQuestionsn nWhat is the difference between ethics committees and ethics consult services?n nHow may ECS help resolve ethical concerns in patient care?ETHICS COMMITTEEn nMUHA Committee within Center for Clinical Effectiveness and Patient Safetyn nChartern nFacilitate shared clinical decision-maki
5、ngFacilitate shared clinical decision-making within ethical framework by patients, family within ethical framework by patients, family members or surrogate decision makers, and staff. members or surrogate decision makers, and staff. n nSubcommittee structureSubcommittee structure on education, polic
6、y on education, policy development and review, and clinical ethics development and review, and clinical ethics consultationconsultationEthics Consultation Service n nService branch of the Ethics Committeen nMultiprofessional groupn nNurses, physicians, chaplains, community Nurses, physicians, chapla
7、ins, community representatives, an attorney, other clinicians representatives, an attorney, other clinicians n nPROVIDING HELP FOR DIFFICULT AND COMPLEX PATIENT CARE DECISIONS n nProviding help with professional conflicts Ethics Consultation Service n nPROVIDING HELP FOR DIFFICULT AND COMPLEX PATIEN
8、T CARE DECISIONSn nIdentify the ethical issuesIdentify the ethical issuesn nIdentify the ethically appropriate treatment optionsIdentify the ethically appropriate treatment optionsn nProvide problem-solving and informational expertiseProvide problem-solving and informational expertisen nPromote effo
9、rts to work out the conflict among the Promote efforts to work out the conflict among the participants, if necessary participants, if necessary Ethics Consultation Service n nDifficult & Complex Patient Care Decisions n ndifferences in opinion among caregivers and/or differences in opinion among car
10、egivers and/or family members about treatment family members about treatment n nend of life decision-making end of life decision-making n nsurrogate decision-makers and/or patient advance surrogate decision-makers and/or patient advance directives directives n nquestions about policies, such as resu
11、scitation or questions about policies, such as resuscitation or withholding/withdrawing life-sustaining treatment withholding/withdrawing life-sustaining treatment Questionsn nHow do Advance Directives differ from Health Care Powers of Attorney?n nWho are health care surrogates and under what standa
12、rd do surrogates act?n nWho may be patient surrogates under SC Law?Advance Directivesn nStatements by competent decision-makersn nInterventions to accept or refuse if they lose Interventions to accept or refuse if they lose decision-making capacitydecision-making capacityn nWho may act as surrogateW
13、ho may act as surrogateAdvance Directivesn nOral Statementsn nTo family members or friendsTo family members or friendsn nInformed? Specific treatment/ situations? Repeated?Informed? Specific treatment/ situations? Repeated?n nTo physiciansTo physiciansn nWritten documentsn nLiving willLiving willn n
14、Health care proxy / power of attorneyHealth care proxy / power of attorneyAdvance Directivesn nOral Statementsn nLimited by court requirements for evidenceLimited by court requirements for evidencen n“Beyond reasonable doubt”“Beyond reasonable doubt”n n“Clear and convincing”“Clear and convincing”n n
15、May require mention of specific intervention and May require mention of specific intervention and clinical situationclinical situationn n“Preponderance of evidence”“Preponderance of evidence”Advance Directivesn nWritten documentsn nLiving willn nDirects physicians to withdraw or withhold Directs phy
16、sicians to withdraw or withhold specific life-saving treatments if patient has specific life-saving treatments if patient has terminal condition or persistent vegetative stateterminal condition or persistent vegetative staten nWhat is “terminal condition”What is “terminal condition”n nWhich treatmen
17、ts “merely prolong dying process”Which treatments “merely prolong dying process” Advance Directivesn nWritten documentsn nHealth care proxy / power of attorneyn nDecision-making priority over other potential Decision-making priority over other potential surrogatessurrogatesn nApplies to all medical
18、situations where decision-Applies to all medical situations where decision-making capacity is lostmaking capacity is lostn nSubstituted judgmentSubstituted judgmentn nPatients previously expressed choices or best interestsPatients previously expressed choices or best interestsHealthcare Surrogaten n
19、Has authority to make healthcare decisions for patient who has lost decision-making capacity n nStandardsn nSubstituted judgment (if patients wishes known)Substituted judgment (if patients wishes known)n n Best interest Best interestn nADULT HEALTH CARE CONSENT ACT n nSC Code of Laws, Title 44 Chapt
20、er 66SC Code of Laws, Title 44 Chapter 66ADULT HEALTH CARE CONSENT ACTn nPriority of Surrogatesn nLegal guardian, attorney-in-fact appointed by the patient in a durable power of attorney, statutory surrogate given priorityn nSpouse, unless legally separated n nParent or adult child of the patient n
21、nadult sibling, grandparent, or adult grandchild of the patient ADULT HEALTH CARE CONSENT ACTn nPriority of Surrogates (2)n nany other relative by blood or marriage who reasonably is believed by the health care professional to have a close personal relationship with the patient;n n person given auth
22、ority to make health care decisions for the patient by another statutory provision. Case Study: 79 year old woman has aged gracefullyn nNo consensus obtained on withdrawal of care. Tracheostomy done and PEG-tube inserted. n nThree months pass. NY sister has accused the local sister and physicians of
23、 wanting to murder mother. NY sister camps out in patients room; local sister visits infrequently; brother has appeared, but has difficulty mediating between sisters.Case Study: 79 year old woman has aged gracefullyn nPatient successfully weaned from ventilator, but no change in mental status. Has s
24、pontaneous eye opening, but does not otherwise respond.n n She develops pneumonia and incipient respiratory insufficiency. Nurses express discomfort about continuing futile care.Questionsn nWhat is persistent vegetative state (PVS)?n nHow do Quinlan, Cruzan, Schiavo cases affect care of persons in P
25、VS?Quinlan, Cruzan, Schiavon nwww.trinity.edu www.trinity.edu nn Vegetative Staten nNo cortical functionn nNo purposeful activity n nCan not obey verbal commandsn nCan not experience pain n nPreserved brainstem functionn nBreathing and circulation intactn nNot comatose (has sleep-wake cycles)Vegetat
26、ive Staten nPreserved brainstem function (2)n nRoving eye movements, may trackn nReflexes intact (not replicable)n nSuck, chew, swallowSuck, chew, swallown nPupillary, oculocephalic, deep tendon reflexesPupillary, oculocephalic, deep tendon reflexesn nWithdrawal, posturing, startle to noiseWithdrawa
27、l, posturing, startle to noisePersistant Vegetative Staten nVegetative state lasting over one monthn nNontraumatic injury waking rare after 3 monthsn nTraumatic injury waking rare after 1 yearn nMean survival 2-5 years, some over 15 yearsPersistant Vegetative Staten nTube feeding requiredn nUnable t
28、o swallow or protect airwayn nIncontinent, requiring total nursing caren nCommon complicationsn nDecubitus ulcersn nAspiration pneumonian nUrosepsisPersistant Vegetative Staten nOther neurologic catastrophesn nBrain death no cortical or brainstem function no cortical or brainstem functionn nLocked-i
29、n syndrome conscious, minimal motor conscious, minimal motorn nSevere dementia conscious, poorly responsive; conscious, poorly responsive; some motorsome motorQuinlan, Cruzan, Schiavon nKaren Ann Quinlan case n n21 year-old woman in PVS on ventilator (1975)21 year-old woman in PVS on ventilator (197
30、5)n nhad ingested alcohol and sedatives during partyhad ingested alcohol and sedatives during partyn nPhysician beliefsPhysician beliefsn nwould never regain consciousnesswould never regain consciousnessn nwould die off ventilatorwould die off ventilatorQuinlan, Cruzan, Schiavon nKaren Ann Quinlan c
31、ase (2)n nFatherFathern nsupported by chaplain, Catholic priest and supported by chaplain, Catholic priest and Diocese of New JerseyDiocese of New Jerseyn n wanted ventilator stopped wanted ventilator stoppedn nrequested court appointment as guardian with requested court appointment as guardian with
32、 authority to stop ventilator when physicians authority to stop ventilator when physicians refusedrefusedQuinlan, Cruzan, Schiavon nKaren Ann Quinlan case (3)n nNew Jersey Supreme Court ruling (1976)New Jersey Supreme Court ruling (1976)n nSUBSTITUTED JUDGEMENTSUBSTITUTED JUDGEMENTn nRight to privac
33、y included right to decline medical Right to privacy included right to decline medical treatment guardian could exercise this right permitted treatment guardian could exercise this right permitted to render best judgment whether whether patient would to render best judgment whether whether patient w
34、ould choose to decline treatmentchoose to decline treatmentn nWithdraw ventilator if guardian, family, physicians, and Withdraw ventilator if guardian, family, physicians, and ethics committee agree no possible recovery of cognitive ethics committee agree no possible recovery of cognitive statestate
35、Quinlan, Cruzan, Schiavon nKaren Ann Quinlan case (4)n nFirst “right to die” caseFirst “right to die” case exploring dilemma that exploring dilemma that life-sustaining interventions inappropriate in some life-sustaining interventions inappropriate in some circumstancescircumstancesn nDecision-makin
36、g by patients, family, and Decision-making by patients, family, and physiciansphysicians without routine recourse to courts without routine recourse to courtsn nHospital ethics committees Hospital ethics committees development development supportedsupportedn nSurvived 10 years PVS post ventilator re
37、movalSurvived 10 years PVS post ventilator removalQuinlan, Cruzan, Schiavon nNancy Cruzan casen n26 year-old woman in PVS post-MVA (1983)26 year-old woman in PVS post-MVA (1983)n nParentsParents asked feeding gastrostomy be removed asked feeding gastrostomy be removed (1986)(1986)n nState hospitalSt
38、ate hospital requested court order requested court ordern nCruzan statementCruzan statement prior to MVA made to prior to MVA made to housemate “not want to live as vegetable” housemate “not want to live as vegetable” family supported statement family supported statementQuinlan, Cruzan, Schiavon nNa
39、ncy Cruzan case (2)n nMissouri Supreme Court (1986)Missouri Supreme Court (1986)n nRestricted decision-making for incompetent patientsRestricted decision-making for incompetent patientsn nwithhold life-sustaining treatment only if living will or withhold life-sustaining treatment only if living will
40、 or clear statement that specific intervention not wanted in clear statement that specific intervention not wanted in specific situationspecific situationn nUnqualified states interest in preserving lifeUnqualified states interest in preserving lifeQuinlan, Cruzan, Schiavon nNancy Cruzan case (3)n n
41、U.S. Supreme Court (1990)U.S. Supreme Court (1990)n nCompetent patientsCompetent patients have “constitutionally have “constitutionally protected liberty interest in refusing unwanted protected liberty interest in refusing unwanted medical treatment”medical treatment”n nConstitution may rely on fami
42、lyConstitution may rely on family decision-making, decision-making, but not requiredbut not requiredQuinlan, Cruzan, Schiavon nNancy Cruzan case (4)n nU.S. Supreme Court (1990)U.S. Supreme Court (1990)n nStatesStates n nmay establish “procedural safeguards” for may establish “procedural safeguards”
43、for medical decisions for incompetent patientsmedical decisions for incompetent patientsn nmay require life-sustaining interventions may require life-sustaining interventions absent clear evidence incompetent patient absent clear evidence incompetent patient would refusewould refuseQuinlan, Cruzan,
44、Schiavon nNancy Cruzan case (5)n nU.S. Supreme Court dissentsU.S. Supreme Court dissentsn nBrennan, Marshall, BlackmunBrennan, Marshall, Blackmunn nFreedom from unwanted treatments is fundamental Freedom from unwanted treatments is fundamental right of competent and incompetent patientsright of comp
45、etent and incompetent patientsn nDecisions for incompetent patients by families or Decisions for incompetent patients by families or patient-designated surrogates patient-designated surrogates Quinlan, Cruzan, Schiavon nNancy Cruzan case (6)n nU.S. Supreme Court dissentsU.S. Supreme Court dissentsn
46、nStevensStevensn nConstitution requires that patients best interest Constitution requires that patients best interest be followed be followedQuinlan, Cruzan, Schiavon nNancy Cruzan case outcomes (6)n nEstablished “right to die”Established “right to die” - tube removed - tube removedn n additional wi
47、tnesses validated Cruzan wishes, physician additional witnesses validated Cruzan wishes, physician decided to support feeding stop, Missouri withdrew court decided to support feeding stop, Missouri withdrew court proceedingproceedingQuinlan, Cruzan, Schiavon nNancy Cruzan case outcomes (7)n nSupport
48、 for legislation on advance directivesSupport for legislation on advance directivesn nstate laws on health proxiesstate laws on health proxiesn nfederal Patient Self Determination Act (1991)federal Patient Self Determination Act (1991)n nwritten advice upon admission written advice upon admission ab
49、out right to advance directive about right to advance directiveQuinlan, Cruzan, Schiavon nTheresa Shiavo casen n27 year-old woman in PVS27 year-old woman in PVS post cardiac arrest due post cardiac arrest due to potassium abnormalities (1990)to potassium abnormalities (1990)n n1998 1998 husband requ
50、ests court to discontinue husband requests court to discontinue feedings; parents oppose feeding tube removalfeedings; parents oppose feeding tube removaln nTrial court ruledTrial court ruled clear evidence patient would want clear evidence patient would want tube removed, decision appealedtube remo
51、ved, decision appealedQuinlan, Cruzan, SchiavonTheresa Shiavo case (2)n n20022002 overwhelming evidence patient in PVS with overwhelming evidence patient in PVS with no potential treatment benefit no potential treatment benefit n nFlorida appellate courtFlorida appellate court denies appeals; Florid
52、a denies appeals; Florida Supreme Court declines caseSupreme Court declines casen n2003 Florida legislature2003 Florida legislature passes “Terris law” passes “Terris law”n nGovernor authorized to stay removal of feeding tube Governor authorized to stay removal of feeding tube challenged by family m
53、emberchallenged by family memberQuinlan, Cruzan, SchiavonTheresa Shiavo case (3)n n20042004 Florida courtFlorida court declares “Terris law” declares “Terris law” unconstitutional Florida Supreme Court affirms unconstitutional Florida Supreme Court affirms decisiondecisionn n2005 Congress2005 Congre
54、ss passes legislation to move case to passes legislation to move case to federal court US Supreme Court refuses casefederal court US Supreme Court refuses caseQuinlan, Cruzan, Schiavon nTheresa Shiavo case outcomes(4)n nFeeding tube removedFeeding tube removedn nWritten advance directiveWritten adva
55、nce directive importance illustrated importance illustratedn nFamily disagreementsFamily disagreements requiring court intervention requiring court intervention highlightedhighlightedQuinlan, Cruzan, Schiavon nTheresa Shiavo case outcomes(4)n nThird party interferenceThird party interference in end-
56、of-life decision- in end-of-life decision-making occurredmaking occurredn nSC actSC act to provide nutrition and hydration to to provide nutrition and hydration to incompetent patient without advanced directive incompetent patient without advanced directive proposedproposedQuestionsn nDoes withholdi
57、ng/withdrawing care differ?n nWhat is “futile care” (medically ineffective treatment)?Withholding/withdrawing Life-sustaining Treatmentsn nNo ethical differencen nCourts consistently rule no difference n nPassive vs active action patient wishes more importantWithholding/withdrawing Life-sustaining T
58、reatmentsn nAutonomy of competent patient/surrogaten nInformed consent justifies treatmentInformed consent justifies treatmentn nInformed refusal justifies foregoing or Informed refusal justifies foregoing or discontinuing treatmentsdiscontinuing treatmentsn nDecide by weighing benefits and burdensn
59、 nMinimize disability and painMinimize disability and painn nRelieve sufferingRelieve sufferingn nAvoid harmAvoid harmFutile treatmentn nOrdinary vs extraordinary treatment no differencen nGiven patient preferences, examine benefit and burden of treatmentsn n*Medically Ineffective Treatment* n nprov
60、ides little/ no benefit with undue burdenprovides little/ no benefit with undue burden *futile*Questionsn nHow does “Allow Natural Death” differ from “Do Not Resuscitate”?n nHow does “distributive justice” affect treatment?AND versus DNRn nDo Not Resuscitate n nrelays patient/family wish no resuscit
61、ation attempts (CPR) start if patient diesn ndoes not stop treatmentchanges goal to comfort care AND versus DNRn nDo Not Resuscitate (2)n nNegative statement generates confusionn n? abandon care and stop all treatment? abandon care and stop all treatmentn n? permission to terminate patients life. ?
62、permission to terminate patients life. n n? family guilt about not sufficiently helping ? family guilt about not sufficiently helping patientpatientn n? unrealistic expectation? unrealistic expectationAND versus DNRn nAllow Natural Deathn nacknowledges patient is dying n ncomfort measures becomes po
63、sitive goaln nreflects language used in SC Declaration of Desire for Natural Death AND versus DNRn nAllow Natural Death (2)n nwithholds or withdraws painful and burdensome treatments (including ventilator, artificial nutrition/hydration, feeding tube) AND versus DNRn nUsing ANDn nFULL SUPPORTn nINTE
64、RMEDIATE SUPPORT - ALLOW - ALLOW NATURALNATURAL DEATHDEATHmedical procedures medical procedures discontinued (vent, IVs, artificial nutrition/ discontinued (vent, IVs, artificial nutrition/ hydration) but if patient arrests no code startedhydration) but if patient arrests no code startedn nCOMFORT S
65、UPPORT - ALLOW NATURAL - ALLOW NATURAL DEATHDEATHall care aimed at comfort. all care aimed at comfort. Distributive Justicen nAllocation of health care resourcesn nFairnessFairness get what deserved get what deservedn nPeople equal ethically, treated equally;People equal ethically, treated equally;
66、different ethically, treated differently different ethically, treated differentlyn nRation time and resourcesRation time and resources according to need, according to need, probability and degree of benefitprobability and degree of benefit AMA Code of Ethics 2.03 Allocation of Limited Medical Resour
67、cesAMA Code of Ethics 2.03 Allocation of Limited Medical ResourcesDistributive Justicen nAdequate health care accessn nDemocratic decisionDemocratic decision after public input during after public input during development and approval stagesdevelopment and approval stagesn nMonitor variationsMonitor
68、 variations in care not medically explained in care not medically explained to avoid ethnic/ racial disparityto avoid ethnic/ racial disparityn nAdjust level of careAdjust level of care over time assuring public over time assuring public acceptanceacceptancen nEqual access to basic care; equal consi
69、deration for discretionary care AMA Code of Ethics 2.097 Provision of Adequate Health Care AMA Code of Ethics 2.097 Provision of Adequate Health CareDistributive Justicen nBarring disaster or prior societal decisions rationing healthcare resources physician shall remain focused upon effective treatm
70、ent of individual patient AMA Principles of Medical Ethics VIII AMA Principles of Medical Ethics VIIIQuestionsn nMay physicians withdraw or withhold care without consent of the surrogate?n nWhat must the physician do for the patient or surrogate if medical staff members ethically feel they can not c
71、ontinue “futile treatment”?Withdraw or Withhold Care without Consent of Surrogaten nNo ethical obligation to render medically ineffective treatmentn nDenial must be justified by ethical principles and acceptable standards of care AMA Code of Ethics 2.035 Futile Care AMA Code of Ethics 2.035 Futile C
72、areStopping medically ineffective treatment without surrogate consentn nObligationsn nto shift care toward comfort/ closuren nto not prolong dying without benefit to patient or legitimate interestn nAll health institutions need policy with due processStopping medically ineffective treatment without
73、surrogate consentn nMedically ineffective treatment policy (1)n nNegotiateNegotiate what constitutes medically what constitutes medically ineffective treatment for patient, and limitsineffective treatment for patient, and limits for physician, surrogate, and institutionfor physician, surrogate, and
74、institutionn nMaximize joint decision-makingMaximize joint decision-making between between patient or proxy and physicianpatient or proxy and physicianStopping medically ineffective treatment without surrogate consentn nMedically ineffective treatment policy (2)n nNegotiate disagreementsNegotiate di
75、sagreements for resolution, for resolution, involving appropriate consultantsinvolving appropriate consultantsn nInvolve ethics committee/ECS, Involve ethics committee/ECS, if unable to if unable to resolve differencesresolve differencesStopping medically ineffective treatment without surrogate cons
76、entn nMedically ineffective treatment policy (3)n nIf institutional review supports patientIf institutional review supports patient and and physician unpersuadedphysician unpersuaded, arrange transfer of care , arrange transfer of care within institutionwithin institutionn nIf institutional review s
77、upports physicianIf institutional review supports physician and and patient/ proxy unpersuadedpatient/ proxy unpersuaded, seek transfer to another , seek transfer to another institution while medically supporting patientinstitution while medically supporting patientn nIf transfer not possible, need
78、not offer treatmentIf transfer not possible, need not offer treatment AMA Code of Ethics 2.035 Medical Futility in End-of- Life AMA Code of Ethics 2.035 Medical Futility in End-of- LifeCase Study: 79 year old woman has aged gracefullyn nPneumonia successfully treated with brief use of ventilator and
79、 antibiotics; however patient develops progressive renal insufficiency. n nA month goes by. Despite skin care patient develops large sacral decubitus. She develops increasing creatinine, edema, and dyspnea.Case Study: 79 year old woman has aged gracefullyn nGranddaughter appears from off; she rememb
80、ers grandmother saying she wanted to go quickly when her time came, but God would decide. Questionsn nDoes euthanasia differ from terminal sedation?n nWhat is the rule of “double effect”?Euthanasia and Palliative Sedationn nActive euthanasian nPhysician provides means and causes patients deathPhysic
81、ian provides means and causes patients deathn nVoluntary patient requests;Voluntary patient requests; involuntary patient opposes; involuntary patient opposes; nonvoluntary patient lacks decision-making nonvoluntary patient lacks decision-makingEuthanasia and Palliative Sedationn nPassive euthanasia
82、 or ANDn nWithholding or withdrawing treatmentWithholding or withdrawing treatmentn nComparable to informed refusal of life-sustaining Comparable to informed refusal of life-sustaining treatment by patient or surrogate; treatment by patient or surrogate; respects patient autonomy respects patient au
83、tonomyn nunderlying illness causes deathunderlying illness causes deathEuthanasia and Palliative Sedationn nPalliative sedationn nHigh dose opiate or sedative with object to relieve High dose opiate or sedative with object to relieve suffering or dyspneasuffering or dyspnean nMay hasten death, but d
84、eath not intendedMay hasten death, but death not intendedn nEnsure excellent palliative care; Ensure excellent palliative care; decision to use informed and voluntary; decision to use informed and voluntary; no depression no depressionRule of Double Effectn nDistinguishes between intended effect and
85、 effects foreseen but unintendedn nApplicable to passive euthanasia and palliative sedation n nBad effect (respiratory depression/ death from opiates) not means of good effect (relief of suffering); unintended but foreseen bad effect proportional to intended good effectQuestionsn nAre dialysis or me
86、dical hydration and nutrition indicated in PVS?n nWhat is the physiologic response to withdrawal of hydration? Medical Hydration and Nutrition or Dialysis in PVS?n nValue judgmentn nWhat is a human being?What is a human being?n nDecisions personal, Decisions personal, often involve religious beliefs
87、 of patient often involve religious beliefs of patientn nEthicallymay withdraw or withhold any intervention in accord with advance directive or surrogate decisionMedical Hydration & Nutritionand Religionn n“Pope declares feeding tube removal immoral.” AP News March 20. 2004 AP News March 20. 2004n n
88、“There should be presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is sufficient benefit to outweigh the burdens involved to the patient.” Ethical and Religious Directives for Catholic
89、 Health Care Services, 4 Ethical and Religious Directives for Catholic Health Care Services, 4thth ed, 2001 ed, 2001Medical Hydration & Nutritionand The Law nNancy Cruzan case (1990)n nMedical hydration & nutrition: treatment subject to refusaln nState has right to “clear and convincing evidence” fr
90、om patient about stopping medical hydration & nutritionMedical Hydration & Nutritionand The Law nHelga Wanglie case (1991)n nUpheld right of husband to continue feeds in PVS though seen as nonbeneficial by health care teamMedical Hydration & Nutritionand SC Lawn nSC Health Care Power of Attorneyn n
91、If no decision re tube feeding, agent has no If no decision re tube feeding, agent has no legal authority to withhold / withdraw medical legal authority to withhold / withdraw medical hydration and nutrition “necessary for comfort hydration and nutrition “necessary for comfort care”care” SC CODE SC
92、CODE SECTION 62-5-504.SECTION 62-5-504. Health care power of attorney Health care power of attorneyMedical Hydration and Nutritionn nHunger rare at end of lifen nArtificial hydration and nutrition can be harmful, increase suffering and prolong dyingn nIf fluid/ food stopped, death from dehydration n
93、ot starvationPhysiology of Terminal Dehydrationn nIncreased endogenous endorphin releasen nAzotemia and uremic encephalopahyn nDecreased body fluidsn nUrine outputUrine outputn nPulmonary secretions/ edemaPulmonary secretions/ edeman nGastric fluids, so decreased vomitingGastric fluids, so decreased
94、 vomitingQuestionsn nHow do cultural and religious differences affect the concept of “good death”?n nHow may hospital chaplains contribute to ethics consultation?“Good Death”n nSome cultural differencesn nTelling person she is dying may not be acceptedTelling person she is dying may not be acceptedn
95、 nSurrounded by family Surrounded by family n nFreedom from pain or indignityFreedom from pain or indignityn nLife preserved at any cost may have valueLife preserved at any cost may have value“Good Death”n nSome religious differencesn nRituals required differ as death approachesRituals required diff
96、er as death approachesn nFaiths weigh ethical principles differentlyFaiths weigh ethical principles differentlyn nAccepting suffering may have valueAccepting suffering may have value“Good Death”n nHow does your cultural tradition define a “good death”?n nWhat is your personal definition of a “good d
97、eath”?Chaplainsn nProvide insight to clinicians about cultural and religious expectationsn nHelp patient, families, and surrogates clarify how their religious beliefs, needs, and desires affect treatment decisionsn nOffer pastoral and emotional support regardless of faith traditionsCase Study: 79 ye
98、ar old woman has aged gracefullyn nEthics consult service has met several times with the Ethics consult service has met several times with the family and medical staff during the patients hospital family and medical staff during the patients hospital stay. ECS each time has offered treatment options
99、. stay. ECS each time has offered treatment options. n nAfter the last ECC visit, the family agreed with the After the last ECC visit, the family agreed with the recommendation for no dialysis, stopping tube feedings recommendation for no dialysis, stopping tube feedings & hydration, and offering opiate sedation based upon & hydration, and offering opiate sedation based upon apparent need for comfort.apparent need for comfort.n nThe patient died peacefully days later. The patient died peacefully days later. Questionn nHave you completed a personal Health Care Power of Attorney?
